Cirugía y Cirujanos.

2015; 83(1): 74-80

CIRUGÍA y CIRUJANOS
Órgano de difusión científica de la Academia Mexicana de Cirugía
Fundada en 1933
www.amc.org.mx www.elservier.es/circir

GENERAL INFORMATION

Eccentric strength training for rotator cuff

tendinopathies with subacromial impingement.
Current evidence☆

Salvador Israel Macías-Hernándeza,* and Luis Enrique Pérez-Ramírezb

a
División de Rehabilitación Ortopédica, Instituto Nacional de Rehabilitación, México Distrito Federal, México
b
Servicio de Rehabilitación, Antiguo Hospital Civil de Guadalajara, Guadalajara, Jalisco, México

Received 7 April 2014; accepted 5 September 2014

KEYWORDS Abstract
Tendinopathy; Background: Rotator cuff tears are the leading cause of pain and functional disability of the
Rotator cuff; shoulder. Conservative treatment is an essential part of their management. Despite the limited
Resistance training evidence, rehabilitation is the mainstay of the treatment for rotator cuff tears associated to
impingement syndrome. There are current reports on the utility of strengthening with resis-
tance, particularly by eccentric exercise.
This report aimsWRSUHVHQWDQRYHUYLHZRIWKHHIÀFDF\RIHFFHQWULFH[HUFLVHVLQWHQGLQRSDWKLHV
DQGFXUUHQWHYLGHQFHRILWVEHQHÀWLQURWDWRUFXIIWHDUV
Four studies published on eccentric strengthening for rotator cuff tears were analysed. There is
theoretical evidence about its usefulness in this pathology, but only a controlled clinical trial
has been published with data on improvement in strength but not in pain or functionality.
Conclusions: More studies are needed with better methodological designs in order to generate
evidence of their utility and recommendation.
© 2015 Academia Mexicana de Cirugía A.C. Published by Masson Doyma México S.A. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

PALABRAS CLAVE: Fortalecimiento excéntrico en tendinopatías del manguito de los rotadores asociadas
Tendinopatía; a pinzamiento subacromial. Evidencia actual
Manguito de
los rotadores; Resumen
Entrenamiento Antecedentes: Las lesiones del manguito rotador son la principal causa de dolor y discapacidad
de resistencia funcional del hombro. El tratamiento conservador es parte fundamental de su manejo. Existen

☆
Please cite this article as: Macías-Hernández S.I. et al. Fortalecimiento excéntrico en tendinopatías del manguito de los rotadores aso-
ciadas a pinzamiento subacromial. Evidencia actual. Cirugía y Cirujanos. 2015; 83: 74-80.
*Corresponding author. Instituto Nacional de Rehabilitación, Calz México Xochimilco N.º 289, Col. Arenal de Guadalupe. C.P. 14389 Tlalpan,
México D.F., México. Teléfono: (01-55) 5999 1000; ext. 13157.
E-mail address: drisraelmacias@gmail.com (S.I. Macías Hernández).

0009-7411/©
2444-0507 2015 Academia Mexicana de Cirugía A.C. Published by Masson Doyma México S.A. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Eccentric strength training for rotator cuff tendinopathies with subacromial impingement. Current evidence 75

publicaciones recientes sobre la utilidad del fortalecimiento excéntrico en este tipo de lesiones
asociadas a pinzamiento subacromial.
El presente reporte tiene como objetivo mostrar un panorama general sobre la utilidad de los
HMHUFLFLRVH[FpQWULFRVHQODVWHQGLQRSDWtDV\ODHYLGHQFLDDFWXDOGHVXEHQHÀFLRHQODVOHVLRQHV
del manguito rotador.
Se analizan 4 estudios publicados sobre fortalecimiento excéntrico en lesiones del manguito
URWDGRU([LVWHHYLGHQFLDWHyULFDVREUHVXXWLOLGDGHQODSDWRORJtDDXQTXHVRORXQHQVD\RFOtQLFR
controlado ha sido publicado con datos sobre mejoría en la fuerza pero no en el dolor o la fun-
cionalidad del hombro.
Conclusiones: Es necesario realizar más estudios con mejores diseños metodológicos para tener
mayor evidencia de su utilidad y poder generar algún grado de recomendación.
© 2015 Academia Mexicana de Cirugía A.C. Publicado por Masson Doyma México S.A. Este es un artículo
Open Access bajo la licencia CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Background
Rotator cuff is the anatomical term to describe the tendon
complex that is made up of the supraspinatus, infraspi-
natus, subscapularis and teres minor muscles. It is an in-
tegral component in shoulder movement and stability. Its
affectation represents one of the main causes of joint pain
and dysfunction1. Approximately 4% of people between 40-
60 years suffer from partial or complete tear and up to
54% of adults over 60 years suffer from this affectation 2.
Its aetiology is multifactorial. Factors related to tear de-
velopment are classified into intrinsic (hypovascularity,
ageing-related metabolic alterations), extrinsic (subacro-
mial compression) and traumatic (acute or repetitive mi-
crotraumatisms)3.
6\PSWRPVFDQEHFODVVLÀHGLQWRJURXSVWKRVHFDXVHG
by subacromial bursitis and tendinitis (pain, inflamma-
tion, reduced mobility) and those caused by tendon tear
(decrepitation, weakness and atrophy). In general, both
types coexist simultaneously4.
LQÀOWUDWLRQVZLWKORFDODQDHVWKHWLFVVWHURLGVRUKLJKPR-
lecular weight hyaluronates, tear debridement or open or
arthroscopic repair9.
In a review published by Cochrane library about rota-
tor cuff lesion management, it was established that there
was scarce evidence to support or reject the efficiency
of one treatment over another 10, though it is generally
recommended to start with the least invasive, conservative
management for a period from 6 to 12 weeks, assess the
response and, in each case, consider surgical treatment2,11.
Despite limited evidence, rehabilitation is the corner-
stone of conservative management for rotator cuff tears
with or without subacromial compression9.
7KHDLPRIUHKDELOLWDWLRQLVWRUHGXFHSDLQDQGWKHLQÁDP-
matory process, favour cicatrisation, maintain and increase
mobility arches and restore glenohumeral and scapulotho-
racic balance. Such goals are accomplished by implementing
therapeutic exercise programs that include different types
of muscular strengthening3.

Eccentric contraction exercise

Subacromial compression
The concept of subacromial compression syndrome was in-
troduced in 1972 by Neer to describe a group of pathologies
that produced pain when raising the shoulder and whose
FDXVHVLQFOXGHGEXUVLWLVWHQGLQLWLVFDOFLÀFDWLRQVDQGURWD-
tor cuff tears5. It was later defined as a mechanic irrita-
tion of the rotator cuff and the bursa when compressed in
the subacromial area and clinically characterized by painful
shoulder abduction, reduced active mobility and progres-
sive loss of strength and muscular function6,7. Such symp-
toms may or may not be associated with tendon complex
tears8.
Treatment of rotator cuff lesions
and subacromial compression
The treatment of rotator cuff tears includes surgical and
non-surgical approaches. Among them are included the use
RIDQDOJHVLFDQGDQWLLQÁDPPDWRU\GUXJVUHKDELOLWDWLRQ
Eccentric strengthening consists of making contractions
while enlarging the muscle or in terms of movement, the
resistance produced by the distance of muscular inserts.
This type of contraction is made when joint movement is
stopped12. Eccentric concentration is coachable and also
presents the following theoretical advantages: preferential
UHFUXLWPHQWRI,,EÀEUHZKLFKVWLPXODWHVTXLFNUHDFWLRQÀ-
EUHVDQGK\SRWKHWLFDOO\LVHIÀFLHQWLQWKHSUHYHQWLRQRI
tendon-related lesions, it increases active muscular ten-
sion, promotes generation of tensions from 30 to 50% higher
than the maximum isometric strength, reduces sensitivity
of Golgi tendon organs, increases the collagen density in
the tendon, consumes little metabolic and nervous energy,
and has a reduced impact on muscular volume. Eccentric
exercise exposes the tendon to a greater burden than con-
centric and, apparently, produces a repair effect after mus-
cular micro-tears13. Some of the inconveniences of eccentric
training may include a high rate of muscular fatigue and
the risk of lesion in the event of training with inappropriate
WHFKQLTXH14.
76
Effects of eccentric concentration on tendons
Alfredson 15 discovered that during every eccentric ex-
HUFLVHVHTXHQFHWKHUHZDVDWHPSRUDU\LQWHUUXSWLRQRI
EORRGÁRZLQWHQGRQQHRYHVVHOV7KLVZDVGHPRQVWUDWHG
through Doppler ultrasonography, by means of which it
was possible to observe tendon vascularity after 12 weeks
of eccentric training16. Some studies also report a reduc-
WLRQRIRIDEQRUPDOÁRZRISHULWHQGLQRXVFDSLOODU\
blood, with effects pain in patients with Achilles tendi-
nopathy17.
Repetitive burden and unburden pattern caused by eccen-
tric exercise provides ongoing mechanical stimulus, which
would induce tendon remodelling, similar to the burden ex-
ercised on the bone during mechanical stimulation with high
IUHTXHQFLHV18.
Langberg et al.19 reported the existence of an increase
of collagen synthesis in damaged tendons as a result of an
eccentric training programme for 12 weeks, as well as an
increase in the concentration of peritendinous type I col-
lagen, which was clinically related to a reduction in pain
OHYHOV6XFKÀQGLQJZDVQRWIRXQGLQKHDOWK\WHQGRQV
Eccentric exercise performed on a regular basis theo-
retically reduces pain due to the ongoing desensitization of
peripheral mechanisms of transmission, the central adapta-
tion by agonist and antagonistic muscular groups, and the
increase in tendon resistance, which reduce the possibility
RIWKHLQÁDPPDWRU\SURFHVV20.
7UHDWPHQWZLWKHFFHQWULFPXVFOHWUDLQLQJLVGHÀQHGE\
some authors as painful, who even use the term “painful
eccentric muscle training.” Said program has provided posi-
tive clinical results in patients with chronic Achilles ten-
dinopathy, in whom histological changes compatible with
IDYRXUDEOHVWUXFWXUDOPRGLÀFDWLRQVRIWKHWHQGRQ21,22 have
been found, although there are recent reports with con-
trary results that show limited effectiveness of the treat-
ment23,24. Therefore, its usefulness is controversial. Some
examples of eccentric contraction exercises for deltoids,
Fig. 1 Eccentric contraction exercise for middle deltoids using
dumbbells. Concentric movement involves shoulder abduction.
Once it is abducted, slow eccentric contraction initiates by ap-
proaching the shoulder to the torso.
S.I. Macías-Hernández et al.
supraspinatus and muscles of the rotator cuff are illustrat-
HGLQÀJXUHV
Eccentric strengthening in rotator cuff lesions
and subacromial compression
With the aim of assessing the existing evidence about the
EHQHÀWRIHFFHQWULFVWUHQJWKHQLQJLQURWDWRUFXIIWHQGLQRSD-
thies, a search was carried out in the Pubmed electronic
database with the terms: “tendon,” “tendinopathy,” “ten-
dinitis,” “eccentric,” “rotator cuff” and “resistance train-
ing.”2QHRIWKHÀUVWWHUPVZDVFRPELQHGZLWKHDFKRIWKH
remaining 3. A total amount of 43 articles was found. After
a clean-up according to the type of study (clinical study),
only 4 studies were left that included treatment of rotator
cuff lesions with eccentric exercises. Most of the articles
found indicate results of rotator cuff lesions associated with
subacromial compression. Due to the scarcity of publica-
tions, it was decided to include the analysis of those 4 arti-
cles in this report. The general characteristics of the studies
included are shown in Table 1.
Jonsson et al.25 revealed the results obtained from a pi-
lot study which included 9 patients (5 women and 4 men,
with an average age of 54 years) who suffered from chronic
shoulder pain, diagnosed with subacromial compression and
rotator cuff lesion, in protocol study for surgical treatment.
They underwent a supervised eccentric training programme
for supraspinatus muscles and deltoids (3 sets of 15 repeti-
tions, twice a day, 7 days a week for 12 weeks). There were
assessments of pain through a visual analogue scale (VAS),
of the level of satisfaction (using Likert’s scale) and func-
tionality (using Constant’s scale). Five of them were satis-
ÀHGZLWKWKHWUHDWPHQWZLWKVLJQLÀFDQWSDLQUHGXFWLRQRI
62 to 18 mm (p < 0.05) and a score increase from 65 to 80 (p
< 0.05) in Constant’s scale. After 52 follow-up weeks, those
ÀYHSDWLHQWVFRQWLQXHGWREHVDWLVÀHGDQGZHUHUHPRYHG
from the surgical waiting list. They continued with VAS of
Fig. 2 Eccentric exercise for anterior deltoids. The arrow indi-
cates contraction direction.
Eccentric strength training for rotator cuff tendinopathies with subacromial impingement. Current evidence 77

Fig. 3 Eccentric exercise for external rotators with pulley in Fig. 4 Eccentric exercise for internal rotators with pulley in
neutral point. neutral point.

31 mm and Constant score of 81. Two of those patients had and isokinetic performance during eccentric abduction in
partial tear of supraspinatus tendon and three of them had subjects with subacromial compression syndrome. Twenty
tendinitis and compression. The authors conclude that, de- patients were included, with an average pain duration of
spite the fact that this is a preliminary study, a long-term 2.8 ± 2.9 years. Five assessments were made, a baseline
EHQHÀFLDOHIIHFWZDVREVHUYHGUHODWHGWRSDLQDQGIXQFWLRQ-
ality with the programme of painful eccentric muscle train-
ing for supraspinatus and deltoids. They also declared to
continue with monitored studies in order to reproduce the
obtained results25.
Bernhardsson et al.26 published a study aimed at assessing
the eccentric training effect on pain intensity and shoulder
functionality in patients with subacromial compression. It
is a sort of “before and after” auto-controlled study, with a
home training programme of supervised exercises and sup-
ported by visits to a physiotherapy clinic. Ten patients with
an average age of 54 ± 8.6 years were included, with an av-
erage pain duration of 12 ± 9.1 months. They underwent the
strengthening programme for 12 weeks; initial pain inten-
sity was measured with VAS, and function with the Patient-
6SHFLÀF)XQFWLRQDO6FDOHWKH&RQVWDQWVFDOHDQGTXDOLW\RI
DQGIRXUVXEVHTXHQWDVVHVVPHQWV)RUWKHIXQFWLRQDOLW\
DVVHVVPHQW'$6+TXHVWLRQQDLUHZDVXVHGDQGLWZDVSUHYL-
ously validated in patients with subacromial compression.
Firstly, both shoulders were assessed with an isokinetic dy-
QDPRPHWHUUHJLVWHULQJWKHPD[LPXPWRUTXHRIUHSHWL-
tions. The exercise protocol was performed twice a week,
every other day, in the same position as the assessment, in
a training range of 60° (20°-80°). For each training day, 3
sets of 10 repetitions were performed with a resting period
of 3 minutes between every set. As a result, the authors
UHSRUWHGVWDWLVWLFDOO\VLJQLÀFDQWGLIIHUHQFHVLQUHODWLRQZLWK
the effect measured by the DASH scale. There were no dif-
ferences (p = 0.25) found between assessments 1 and 2.
However, assessment 4 showed lower values compared to
assessment 1 (p < 0.01), 2 (p = 0.02) and 3 (p = 0.02); like-
ZLVHWRUTXHSHDNWRWDOZRUNDQGDFFHOHUDWLRQLPSURYHG
life using the Western Ontario Rotator Cuff Index. The au- VLJQLÀFDQWO\DIWHUWKHLQWHUYHQWLRQS7KLVVWXG\LQ-
WKRUVUHSRUWHGWKDWSDLQLQWHQVLW\GHFUHDVHGVLJQLÀFDQWO\LQ dicates that isokinetic training with eccentric exercise for
8 out of 10 subjects and all the patients saw improvement shoulder abductors improves the physical function of the
in their shoulder function. The average Constant score in- upper extremity in patients with subacromial compression
FUHDVHGVLJQLÀFDQWO\IURPWRSRLQWVS DQG
the average score of the Western Ontario Rotator Cuff Index
increased from 51 to 71% (p = 0.021). The authors concluded
that a strengthening training programme with eccentric ex-
ercises for rotator cuff muscles and the scapular waist can
be effective in pain reduction and increases functionality in
patients with tendinitis and subacromial compression, when
the right pattern of movement is followed26.
Camargo et al.27 reported a series of cases aimed at as-
VHVVLQJWKHEHQHÀWVRIHFFHQWULFWUDLQLQJIRUVKRXOGHUDE-
ductors related to pain, the physical-functional condition
syndrome27.
Maenhout et al. 28 published the only controlled
randomized clinical study so far, in which 61 patients di-
agnosed with subacromial compression were included.
They were randomly divided into 2 groups: a control group
with conservative treatment for subacromial compres-
sion (n = 30, average age of 39.4 ± 13.1 years) and an ex-
perimental group, which included conventional treatment
and eccentric training (n = 31, average age of 40.2 ± 12.9
years). The isometric force was measured in abduction
ranges of 0°, 45° and 90° for rotations. In order to mea-
 78
Table 1 Characteristics of reported studies on eccentric exercises in rotator cuff lesions.

Article Year Objective Type of Participants Details and period Outcome Results Conclusion
study of intervention measures
Jonsson 2006 To assess the effects Pilot 9 patients (5 men and 4 Eccentric Constant’s 5 patients had positive A long-term
et al.25 of an eccentric women). Average age of contraction scale and VAS results, with a decrease EHQHÀFLDOHIIHFWZDV
training programme 54 years, average pain exercise, 3 series of in VAS of 80 to 18 mm observed in relation
for deltoids and duration 41 months, with 10 repetitions twice and an increase in the to pain management
supraspinatus in rotator cuff tear and a day, 7 days a week score of the Constant and functionality in
patients with chronic subacromial compression for 12 weeks. scale from 50 to 67 a small group of
shoulder pain points. patients
Bernhardsson 2011 To assess the effect Auto- 10 patients, average age Home exercise Shoulder 6LJQLÀFDQWSDLQ An eccentric training
et al.26 of eccentric training controlled of 54 years and pain program, with functional reduction in 8 out of 10 program can be
on pain and study duration of 12 months. eccentric scales, subjects and function effective in pain
functionality With partial tears of contraction TXDOLW\RIOLIH improvement in all of reduction and
rotator cuff and exercises for and VAS them increase
subacromial compression supraspinatus and functionality in
infraspinatus, 3 patients with
series of 15 tendinitis and
repetitions, twice a subacromial
day on a daily basis compression
for 12 weeks
Camargo 2012 To assess the Series of 20 patients, 7 women and Eccentric training of DASH Functional differences in Isokinetic training
et al.27 usefulness of cases 13 men, with subacromial 5 repetitions for functional ÀQDODVVHVVPHQWV with eccentric
eccentric training for compression, with an shoulder abductors scale regarding score in DASH exercise for shoulder
shoulder abductors average age of 34 years, with maximum scale abductors improves
in relation to pain, average pain duration of effort with physical function in
the physical- 2.8 years. With tendinitis isokinetic patients with
functional condition or tendinosis of rotator HTXLSPHQWDW subacromial
and isokinetic cuff and subacromial and 180° speed, 2 compression
performance in compression days a week for 6 syndrome
subjects with weeks.
subacromial
compression

S.I. Macías-Hernández et al.

Maenhout 2013 To assess the Controlled 61 patients randomly Physical therapy SPADI The score of SPADI scale The experimental
et al.28 usefulness of clinical divided into 2 groups, program, functional GHFUHDVHGVLJQLÀFDQWO\ JURXSVLJQLÀFDQWO\
implementing study average age of 39 and 40 experimental group scale in both groups. The improved their muscle
eccentric training in years. With tendinitis or with eccentric experimental group gain strength, but there
conventional tendinosis of rotator cuff training for 12 15% strength in were no differences in
management and subacromial weeks abduction as compared the functional scale
compression with the control group
Eccentric strength training for rotator cuff tendinopathies with subacromial impingement. Current evidence
VXUHSDLQDQGVKRXOGHUIXQFWLRQWKH63$',TXHVWLRQQDLUH
was used. In the same manner, patients were asked about
their subjective perception of improvement. Both groups
underwent physiotherapy for 12 weeks with ongoing su-
pervision. At home, the control group performed rotator
cuff strengthening exercises once a day. The experimental
group performed the same exercises once a day and ec-
centric exercise with burden twice a day. At the end of
WKHWUHDWPHQWWKHUHZDVDVLJQLÀFDQWRYHUDOOLQFUHDVHLQ
strength in both groups. Moreover, the score of the SPA-
',VFDOHGHFUHDVHGVLJQLÀFDQWO\7KHH[SHULPHQWDOJURXS
gained 15% strength in scapular abduction compared to the
control group, even though there were no differences in
their perception of improvement. The authors concluded
that adding eccentric training with burden resulted in
gaining strength, but it was not better to reduce pain and
improve shoulder function28.
Conclusions
Published studies show positive results in favour of the use
of this kind of exercise in tendinopathies related to the ro-
tator cuff. However, only one controlled clinical study shows
objective improvement in strength, but not in pain manage-
ment or functionality.
It is necessary to take into consideration that all studies
included patients diagnosed with rotator cuff lesions related
to subacromial compression, so it is important to include
subjects without compression and determine whether that
JURXSZRXOGDOVREHQHÀWIURPWKLVWUHDWPHQW
Further studies need to be carried out, with better de-
signs and a larger number of patients in order to obtain
better evidence and to be able to provide some grade of
recommendation about its usage, which cannot be estab-
lished with the current data.
&RQÁLFWRILQWHUHVW
7KHDXWKRUVGHFODUHWKDWWKHUHDUHQRFRQÁLFWVRILQWHUHVW
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